Recovery of Visuospatial Neglect With Standard Treatment: A Systematic Review and Meta-Analysis

BACKGROUND: Visuospatial neglect is a common consequence of stroke and is characterized by impaired attention to contralesional space. Currently, the extent and time course of recovery from neglect are not clearly established. This systematic review and meta-analysis aimed to determine the recovery trajectory of poststroke neglect with standard treatment. METHODS: PsycInfo, Embase, and MEDLINE were searched for articles reporting recovery rates of neglect after stroke. Time since stroke was categorized into early (0–3 months), mid (3–6 months), and late (>6 months) recovery phases. Random-effects models for pooled prevalence were generated for each phase, and potential sources of heterogeneity were explored with metaregressions. Methodological quality of each study was assessed using the Joanna Briggs Institute checklist, with low-quality studies excluded in sensitivity analyses. RESULTS: The search captured 4130 articles including duplicates, and 111 full-text reviews were undertaken. A total of 27 studies reporting data from 839 stroke survivors with neglect were included for review. Meta-analyses indicated a recovery rate of 42% in the early phase, which increased to 53% in the mid-recovery phase. Additional recovery in the late phase was minimal, with an estimated 56% recovery rate. Heterogeneity of studies was high (I2>75%) in all 3 phases of recovery. Estimates were robust to sensitivity analyses. Metaregressions showed significantly greater recovery in studies that included patients with left-hemisphere lesions (β=0.275, P<0.05, I2=84%). CONCLUSIONS: Most recovery from neglect occurs in the first 3 months, although additional gains can be expected up to 6 months poststroke. While a large proportion of patients recover from neglect, over 40% show persistent symptoms. Further research is needed on effective rehabilitation interventions, particularly focusing on patients most at risk of chronic visuospatial neglect. REGISTRATION: URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42023388763.


Search strategy
The following search was carried out on OVID to search the PsycInfo, Embase, and MEDLINE databases: (stroke* or cerebrovascular accident* or ischemic stroke* or hemorrhagic stroke* or embolic stroke* or brain stem infarct* or thrombotic stroke* or paralytic stroke* or lacunar stroke* or completed stroke* or cardioembolic stroke* or syndrome of little stroke*, neurological or cerebellar stroke* or progression stroke* or occlusive stroke* or thromboembolic stroke* or stroke test response* or infarct* or cerebrovascular disease* or acute stroke* or CVA* or cerebrovascular apoplexy or vascular accident*, brain* or cerebrovascular stroke*

Sensitivity analyses
Sensitivity analyses excluded all studies rates as low quality on the JBI (n = 6).Meta-analyses indicated a recovery rate of 38% (CI = 20-58%, I 2 = 88%) in the early phase (0-3 months), based on 10 studies with 242 stroke survivors.Recovery rates increased to 53% (CI = 32-72%, I 2 = 91%) at 6 months post-stroke across 9 studies of 395 patients.There were no further changes in the late recovery phase (>6 months), with an estimated pooled prevalence of 56% (CI = 41-71%, I 2 = 78%) following analyses of 9 studies with 213 stroke survivors.Selection process 8 Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and if applicable, details of automation tools used in the process. p.2

Data collection process
9 Specify the methods used to collect data from reports, including how many reviewers collected data from each report, whether they worked independently, any processes for obtaining or confirming data from study investigators, and if applicable, details of automation tools used in the process.

p.2-3
Data items 10a List and define all outcomes for which data were sought.Specify whether all results that were compatible with each outcome domain in each study were sought (e.g. for all measures, time points, analyses), and if not, the methods used to decide which results to collect. p.3 10b List and define all other variables for which data were sought (e.g.participant and intervention characteristics, funding sources).Describe any assumptions made about any missing or unclear information.

p.2-3
Study risk of bias assessment 11 Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently, and if applicable, details of automation tools used in the process.

p.2-3
Effect measures 12 Specify for each outcome the effect measure(s) (e.g.risk ratio, mean difference) used in the synthesis or presentation of results.p.3-4

Synthesis methods
13a Describe the processes used to decide which studies were eligible for each synthesis (e.g.tabulating the study intervention characteristics and comparing against the planned groups for each synthesis (item #5)).

p.3-4
13b Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions.

# Checklist item
Location where item is reported 13c Describe any methods used to tabulate or visually display results of individual studies and syntheses. p.4 13d Describe any methods used to synthesize results and provide a rationale for the choice(s).If meta-analysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used. p.3-4 13e Describe any methods used to explore possible causes of heterogeneity among study results (e.g.subgroup analysis, meta-regression).p.4 13f Describe any sensitivity analyses conducted to assess robustness of the synthesized results.p.4

Reporting bias assessment
14 Describe any methods used to assess risk of bias due to missing results in a synthesis (arising from reporting biases).N/A Certainty assessment 15 Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome.N/A

Study selection 16a
Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow diagram.
p.4, Figure 1 16b Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excluded.p.4

Study characteristics
17 Cite each included study and present its characteristics.p.4-5, Table 1 Risk of bias in studies 18 Present assessments of risk of bias for each included study.p15, Table 2 Results of individual studies 19 For all outcomes, present, for each study: (a) summary statistics for each group (where appropriate) and (b) an effect estimate and its precision (e.g.confidence/credible interval), ideally using structured tables or plots.
p.17, Figure 2 and 3 Results of syntheses 20a For each synthesis, briefly summarise the characteristics and risk of bias among contributing studies.p.15, p.17, p.19 20b Present results of all statistical syntheses conducted.If meta-analysis was done, present for each the summary estimate and its precision (e.g.confidence/credible interval) and measures of statistical heterogeneity.If comparing groups, describe the direction of the effect.
p.17, Figure 3 20c Present results of all investigations of possible causes of heterogeneity among study results.p.17

Figure S1 .
Figure S1.Forest plots of neglect recovery stratified by phase for studies of moderate and high quality

20d
Present results of all sensitivity analyses conducted to assess the robustness of the synthesized results.pof risk of bias due to missing results (arising from reporting biases) for each synthesis assessed. of certainty (or confidence) in the body of evidence for each outcome assessed.N/ADISCUSSION ).mp AND (neglect* or hemi#neglect* or sensory neglect* or visual neglect* or visuospatial neglect* or visual#spatial neglect or hemi#sensory neglect* or spatial neglect* or neglect of left side of body or hemi#motor neglect* or decreased spatial neglect* or unilateral neglect* or unilateral spatial neglect or hemi#sensory neglect or inattenti* or motor neglect* or vis* spatial percept*).mpAND ((cogniti* assessment* or cogniti* test or cogniti* task or neuropsychology* test* or neuropsychology* assessment* or neuropsychology* task* or cancellation task* or target cancel* or copy*) and draw* task*) or copy* or clock test* or line bisect* or visual field task* or Catherine Bergego Scale or CBS or stroke impact scale or SIS or national institutes of health stroke scale or NIHSS or stroke impact scale or SIS or behavioural inattention test or BIT or oxford cognitive screen or OCS or Semi-structured Scale for Functional Evaluation of Hemi-Inattention or measure o measur*).mp

Table S1 .
Meta-regression results of lesion side and time of first assessment Objectives4 Provide an explicit statement of the objective(s) or question(s) the review addresses.p.1-2METHODSEligibility criteria 5 Specify the inclusion and exclusion criteria for the review and how studies were grouped for the syntheses.p.2-3Information sources 6 Specify all databases, registers, websites, organisations, reference lists and other sources searched or consulted to identify studies.Specify the date when each source was last searched or consulted.p.2Search strategy 7 Present the full search strategies for all databases, registers and websites, including any filters and limits used.Supplemental Material